Anthem Blue Cross Connecticut CG-MED-48 Scrotal Ultrasound Form

This document addresses the use of ultrasound imaging technologies for the evaluation of conditions affecting the scrotum and testes.

Clinical Indications

Medically Necessary:

The use of scrotal ultrasound is considered medically necessary for the following conditions:

1. Evaluation of acute scrotal symptoms (for example, pain, swelling) and trauma; or
2. Evaluation of scrotal asymmetry or enlargement (including suspected hydroceles); or
3. Evaluation of scrotal masses; or
4. Detection or evaluation of varicoceles; or
5. Evaluation of infertility; or
6. Evaluation of testicular ischemia or torsion; or
7. Evaluation of suspected infectious or inflammatory scrotal disease; or
8. Detection of occult primary tumors in individuals with metastatic germ cell tumors.

Not Medically Necessary:

The use of scrotal ultrasound is considered not medically necessary for the localization of undescended testes.

The use of scrotal ultrasound is considered not medically necessary for any condition not listed above.